Failure to Provide Social Services and Decision-Making Support
Penalty
Summary
The facility failed to provide necessary social services for two residents, resulting in delays in care and services. For one resident with paraplegia, obesity, and depression, the individual requested a larger mattress for comfort and safety, as the current mattress was too small for the bed frame. The social services director acknowledged awareness of the issue and discussed it with the maintenance department but did not document the conversation or follow up to ensure the request was fulfilled. Both the LVN and DON confirmed the mattress was inadequate and that the resident had the right to a comfortable and safe environment, as outlined in facility policy. For another resident with dementia, mood disorder, and anxiety, the individual was found to have severely impaired cognition and was unable to make medical decisions. Despite this, the resident was allowed to sign consents for psychoactive medications, even though staff, including the LVN and RN supervisor, recognized that the resident did not understand what was being signed. The social services director admitted that a conservatorship should have been pursued for this resident but had not taken steps to initiate the process. Facility policies reviewed indicated the importance of providing a homelike environment and ensuring residents' rights, including proper consent for psychotropic medication use. The lack of follow-up and documentation by the social services director, as well as the failure to secure appropriate decision-making support for a resident unable to consent, directly contributed to the deficiencies identified by surveyors.